Kurt Darr

The Centers for Medicare and Medicaid Services Proposal to Pay for Performance

he Centers for Medicare and Medicaid Services (CMS) has launched T a pilot program to determine the feasibility of paying hospitals bonuses based on how well they achieve certain clinical outcomes. Does this mean that market-driven pay-for-performance has come to government-sponsored entitlement programs? It’s too early to judge. What’s certain, however, is that we’ll get what we pay for. Want more patients who smoke to receive education in smoking cessation? Want more patients to leave the hospital with a prescription for ACE inhibitors? Want less of this or more of that? Pay-for-performance will almost certainly provide it. But, at what cost? Pay-for-performance sounds just like management by results (MBR). There is little good that can be said about MBR-but, more on that later. This Nexus column considers the CMS proposal from a manager‘s and public policy perspective. The CMS pilot program builds on a voluntary quality information initiative launched by the American Hospital Association, the Federation of American Hospitals, and the Association of Amer-

Nexus: Ethics, Law, and Management: Cultural, Ethnic, and Religious Diversity in Service Delivery

istorically, the major sources of complexity in managing health services organizations (HSOs) have come from the regulatory, fiscal, and political forces in the external environment. To be effective, however, managers must have a basic understanding of the implications of cultural, ethnic, and religious diversity, as the number of Americans whose culture, ethnicity, and religion differ from those of the American mainstream increases. This means that the expectations and needs of diverse staff and, as important, the various patients treated in HSOs must be understood and met to the greatest extent possible. HSOs already respond to the special needs of their patients in ways such as providing translators, using non-English signage, and meeting special dietary requirements. Urban and medical center HSOs were among the first to encounter these special needs, but as the variety and types of diversity have increased in suburban and rural communities, the need to respond appropriately has become more widespread. Generally, all efforts within reason should be made to accommodate the special needs presented by various cul-

Organizational leadership in hospitals.

Hospitals face very dynamic environments and must meet diverse needs in the communities they serve and respond to multiple expectations imposed by their stakeholders. Coupled with these variables, the fact that leadership in these organizations is a shared phenomenon makes organizational leadership in them very complicated. An integrative overview of the organizational leadership role of CEOs in hospitals is presented, and determinants of success in playing this role are discussed.

Nexus: Implementing Advance Directives: A Continuing Problem for Provider Organizations

It has been suggested that widespread use of advance directives might encourage systematic rationing of healthcare, especially to the elderly. If a right to die becomes a duty to die, the living will and its progeny have become a Frankenstein monster. Indeed, public statements by state and federal officials that the elderly should be required to have living wills raised a storm of protest in the past. Regardless of true motives, such suggestions tend to be seen by the public as motivated by economics. The organization must be alert to the issues raised by advance directives. Managers are obliged to obey the law. Beyond that, however, they should work to enhance patient autonomy by facilitating preparation and availability of advance directives and surrogate decision making, should that become necessary.

Nexus: Futile Treatment and the Health Services Manager

or millennia physicians have been admonished to “comfort, always” I and “first, do no harm,” or

Management Education in Public Health: Further Considerations; Comment on “Management Matters: A Leverage Point for Health Systems Strengthening in Global Health”

mum non noccrc. Further, the Hippocratic oath severely constrained the physician’s actions regarding a patient’s death: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect” (Beauchamp and Walters 1999). Thus, the Hippocratic ethic precluded physicians from actively euthanizing patients, with or without their consent, as well as assisting in a suicide. This meant that the historical role of physicians was to provide palliation for pain and the comfort care needed to make dying as peaceful as possible. It was always suspected that some physicians hastened dying at a patient’s request, or sometimes without it. This sub rosa aid in dying rarely reached the level of public debate. As I suggested in the last Nexus column, however, that has changed. Futility theory is yet another dimension of the problems wrought at the end of life. In a real sense futility theory returns physicians to their traditional role because it does

Katrina: Lessons from the Aftermath

Knowing and applying the basic management functions of planning, organizing, staffing, directing, and controlling, as well as their permutations and combinations, are vital to effective delivery of public health services. Presently, graduate programs that prepare public health professionals neither emphasize teaching management theory, nor its application. This deficit puts those who become managers in public health and those they serve at a distinct disadvantage. This deficit can be remedied by enhanced teaching of management subjects.

Quality Improvement: The Pioneers

The crisis that was Hurricane Katrina caused several ethical and managerial dilemmas, which will provide further guidance as we begin to plan for the avian flu pandemic that the experts tell us is (to use a theater metaphor with a double entendre) waiting in the wings. The huge natural disaster resulting from Katrina and its aftermath engulfed nursing homes and hospitals, which faced the daunting prospect of caring for severely ill patients as a cascade of events interfered with their ability to provide even the most rudimentary care. Caregivers faced a widening catastrophe that included failed public electrical and water service, failure of emergency electrical generators, and, with rising flood waters, the critical need to move patients who were too ill to transport. This resulted in nursing home residents abandoned to rising flood waters, allegations of euthanizing of hospital patients who could not be moved, and troubling questions of whether those who should have known better failed to plan for the extremes that were Katrina and its after-math. With staff scattered, facilities and equipment damaged or ruined, and demand building as residents return, efforts to deliver health services in New Orleans now face a catastrophe in slow motion.

The uninsured: a reality check.

odern history is replete with figures who have striven to improve the quality of medical care. They have included physicians, nurses, managers, and statisticians. Often, the reformers among them were vindicated, some sooner and some later. Their like-minded successors fared somewhat better. Their struggles against established medical practice, however, show the difficulties of changing a profession’s trajectory, even when empirical evidence clearly supports the need for change. The work of some reformers is an expression of what is presently called evidence-based medicine, which has become the gold standard for medical practice. Even as modern allopathic (Western) medical practice has come to be synonymous with the scientific method, there are numerous, disturbing examples of how the medical profession stifled innovation and crushed those whose empirical evidence contradicted what medical orthodoxy knew to be true. Nevertheless, through the tireless work of these pioneers, we have come to benefit from advances in the quality of medical care occurring over the last three centuries.

Assistance in Dying: Part I. Europe—The Vanguard

ven in a country with almost 300 million inhabitants, it would E seem a fairly simple task to accurately estimate the number of people without health insurance. Yet, a review of the several sources of estimates suggests that there is no agreement on the true number of uninsureds. Apparently definitions vary, as do the methodologies used to make them. One must be skeptical of estimates when definitions are lacking. Are the estimators unable or unwilling to define insured? Is there a hidden agenda? Is there a political motivation for the estimates that are made? Lacking such detail makes one skeptical of the estimators’ motives. As statisticians are wont to say, “Figures don’t lie, but liars can figure.”